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NEW PATIENT QUESTIONNAIREPatient Name: Age Birthdate Race White African American Hispanic Asian Other Refuse to reportEthnicity White African American Not Hispanic Other Refuse to reportLanguage English
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To fill out the race/ethnicity section of a form that includes options for white, African American, and Hispanic, follow these steps:
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Read the instructions on the form carefully to determine how to fill out the race/ethnicity section.
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Determine your own race and ethnic background by self-identification.
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If you identify as white, select the option that corresponds to your race.
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If you identify as African American, select the option that corresponds to your race.
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If you identify as Hispanic, select the option that corresponds to your ethnicity.
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If you identify as both white and Hispanic, choose the options that apply to your racial and ethnic background.
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If the form allows multiple selections, choose all the options that apply to you.
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If none of the given options accurately represent your race or ethnicity, check if the form provides an 'Other' or 'Prefer not to say' option. If available, select the appropriate option.
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Anyone who is filling out a form that requires demographic information may need to indicate their race and ethnicity, including options for white, African American, and Hispanic.
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White African American Hispanic refers to individuals who identify as both white, African American, and Hispanic.
Individuals who identify as white, African American, and Hispanic may be required to file under this category for certain surveys or forms.
To fill out white African American Hispanic, simply select all that apply on the given form or survey.
The purpose of including white African American Hispanic as an option is to accurately capture the racial and ethnic identities of individuals.
Individuals may be asked to provide additional information on their specific racial and ethnic backgrounds when selecting white African American Hispanic.
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